Although they are rarely awarded under current law, it is the threat of punitive damages that helps increase safety in every industry, including in nursing homes and long-term care facilities. Making the legislation worse, the Pennsylvania House stripped from the bill a provision that would have at least allowed punitive damages if there were evidence of illegality -- including inadequate staffing, training and oversight.

As it is, too many for-profit nursing homes place their profits ahead of safety. Passage of limits on punitive damages would give them virtual immunity from being held responsible for that decision.

The article, "Highmark to Require More Pre-Authorizations," June 20, states that Highmark will now require pre-authorization after eight visits for physical medicine including chiropractic, physical therapy and occupational therapy.

But in reality, patients will get much less than eight visits. Many patients with severe musculoskeletal conditions such as herniated disc of the neck or low back require multiple forms of physical medicine to resolve their condition. They may only receive one or two visits.

Virginia Calega, Highmark's vice president of medical management and policy, feels there is "unwarranted variation" in chiropractic care. I wonder if Ms. Calega has ever spoken with a chiropractor or has done any research on chiropractic care and treatment.

If we limit chiropractic, physical therapy and occupational therapy, what choice do patients have?